Overview: TB Case Management and Contact Investigation

Transcription

1 Overview: TB Case Management and Contact Investigation Karen A Martinek, RN, MPH Alaska DHSS, DPH, Section of Epidemiology Overview Define tuberculosis (TB) case management Describe the roles and responsibilities of a PHN TB Nurse Case Manager Review contact investigation (CI) goals Discuss how to prioritize cases and contacts for CI Review contact screening and follow-up 2 Nurse TB Case Management: the Toughest Job You ll Ever Love 3 1

2 What is TB Case Management? A collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services available to meet an individual s health needs, using communication and available resources to promote quality, costeffective outcomes Kenyon et al, Case Management Goals Render patient non-infectious by ensuring adequate course of treatment Prevent TB transmission / development of disease Identify / remove barriers to adherence Identify / address other urgent needs 5 Case Management Responsibilities (1) Ensure that the patient: Completes an appropriate course of treatment Is educated about TB, its treatment, management, and adverse reactions Has documented culture conversion Has a contact investigation completed when indicated 6 2

3 Case Management Responsibilities (2) Ensure that: Patient completes medical evaluation / followup (clinical and toxicity monitoring) Response to therapy is evaluated regularly Treatment regimen adjusted, as needed Additional responsibilities: Ensure adequate supply of drugs Identify, train and monitor Directly Observed Therapy (DOT) Aide Submit information / reports to AK TB Program 7 Patient-centered Care Clinical Care Nurse TB Patient Nurse Community Nurse Socioeconomic Emotional Support Support Adapted from: Bayona, J. The community based model of MDR-TB treatment. IUATLD NAR meeting; Vancouver, B.C. 2/ TB Case Management: Key Components (1) Establish therapeutic relationship with the patient an essential partnership Ongoing assessment of patient status Educate all patients / families about TB Ensure that TB treatment is continuous, appropriate, and completed 9 3

4 TB Case Management: Key Components (2) Monitor patient s status / response to treatment through completion Contact investigation identify, evaluate, and follow-up on all contacts Address urgent health / other needs Ensure that staff have knowledge, skills, and caring attitude 10 TB Case Management: Key Components (3) Provide culturally sensitive / acceptable care Set goals, monitor outcomes, and appropriately document interventions Maintain communication with the primary care provider and patient s team 11 The Case Management Process 1. Receive case report 2. Communicate with provider 3. Assess client 4. Develop treatment plan 5. Implement plan 6. Evaluate plan, ongoing 12 4

5 The microbe is nothing the terrain everything Louis Pasteur Case Management Challenges Public-private care coordination Transitions Co-morbidities Homelessness, substance abuse, mental illness Patients that move Cultural beliefs and language issues Drug resistance (particularly if MDR) Staffing shortages and staff turnover 5

6 Contact Investigation Contact Investigations A Crucial Prevention Strategy On average, 10 contacts are identified for each person with infectious TB in the U.S. 20% 30% of all contacts have LTBI 1% of contacts have TB disease Of contacts who will ultimately have TB disease, approximately one-half develop disease in the first year after exposure Benefits of Contact Investigations Finding and treating additional TB disease cases (potentially interrupting further transmission) Finding and treating persons with LTBI to avert future cases 6

7 Contact Investigations: a Public Health Responsibility Decision to investigate an index patient depends on likelihood of transmission and risk to contacts Need to determine Priority of case e.g. 4+ AFB, cavitary, coughing? Which contacts to evaluate first? May require partnering e.g. CHA/Ps Complicated Many interdependent decisions Time-consuming interventions Documentation National TB Program Objectives At least 95% of contacts to sputum AFB smear positive TB cases will be evaluated for infection and disease. The Reality in Alaska: In 2013, 90% of contacts to AFB smear positive cases were examined. National TB Program Objectives At least 85% of infected contacts to sputum AFB smear positive TB cases will complete therapy. The Reality in Alaska: In 2013, 82% of infected contacts to AFB smear positive cases started and completed therapy. 7

8 Definitions of abbreviations: AFB = acid-fast bacilli; C/W = consistent with; CXR = chest radiograph; TB = tuberculosis. * Use time frames from the middle column of Table 2 in the Time Frames for Contact Investigation topic. Use time frames from the right-hand column of Table 2 in the Time Frames for Contact Investigation topic. Source: CDC. Guidelines for the investigation of contacts of persons with infectious tuberculosis: recommendations from the National Tuberculosis Controllers Association and CDC, and guidelines for using the QuantiFERON -TB Gold test for detecting Mycobacterium tuberculosis infection, United States. MMWR 2005;54(No. RR-15):5. Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes Decision to Initiate Contact Investigation Highest priority for contact investigation. pulmonary, laryngeal or pleural TB: AFB sputum smear positive or cavitary lesion on CXR Evaluation, Treatment, and Follow-up of Immunocompetent Adults and Children Five Years and Older (High- and Medium Priority Contacts) 8

9 How to clear and manage contacts Tuberculin skin test (TST) or interferon gamma release assay (IGRA) Now and repeat in 8-10 wks. if negative Consider window prophy for high risk contacts TSTs for children < 5 yrs. of age If prior (+) TST symptom screening, sputa Newly infected contacts = LTBI treatment priority Evaluation of Persons with Positive TB Test Results Person has a positive test for TB infection TB disease ruled out Consider for LTBI treatment Person accepts and is able to receive treatment of LTBI Develop a plan of treatment with patient to ensure adherence If person refuses or is unable to receive treatment for LTBI, follow-up TST or IGRA and serial chest radiographs are unnecessary Educate patient about the signs and symptoms of TB disease Treatment Regimens for Latent TB Infection Drug(s) Duration Interval Minimum Doses Isoniazid 9 months Daily 270 Twice weekly 76 6 months Daily 180 Twice weekly 52 Isoniazid & Rifapentine 3 months Once weekly 12 Rifampin 4 months Daily 120 Note: Rifampin (RIF) and Pyrazinamide (PZA) should not be offered to persons with LTBI. RIF and PZA should continue to be administered in multidrug regimens for the treatment of persons with TB disease. 9

10 References / Resources Kenyon, V., Smith, E., Hefty, L., Bell, M.L., McNeil, J. & Winter, B. (1990). Clinical competencies for community health nursing. Public Health Nursing, 7 (1), National Tuberculosis Controllers Association, National Tuberculosis Nurse Consultant Coalition. Tuberculosis nursing: a comprehensive guide to patient care, second edition. 2011; New Jersey Medical School National Tuberculosis Center. Tuberculosis case management for nurses: self-study modules Module 2, Fundamentals of Tuberculosis Case management. er%20selfstudy%20modules/complete%20ncm%20ssm% pdf U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Core curriculum on tuberculosis: what the clinician should know, sixth edition, 2013: Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosis: Recommendations from the National Tuberculosis Controllers Association and CDC. MMWR 2005; 54 (No. RR 15)